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Acute Myelogenous Leukemia Olivia Wagner

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•Patient Hx.•Diagnosis•Etiology AML•Treatment Plan

•Medical/Surgical•Nutrition Therapy

•Patient Response to Tx.•Patient Prognosis•Questions

+Patient Hx: Name: Rachel Dean

Chemical Engineer Married Age: 25 Sex: Female Wt: 115 (46.8 kg) Ht: 5’3” (1.6 m) BMI: 20.3 Not a smoker Family hx: maternal CAD

Diagnosis of Acute Myelogenous Leukemia (AML) Sinus infection symptoms >3 months Chemistry panel and CBC revealed elevated WBC and blasts

Onset of disease: 4 months PTA

Induction Chemotherapy cytarabine and idarubicin 1st CR achieved

Dx: Acute Leukemia in CR. Admitted for bone marrow transplant

+Acute Myelogenous Leukemia (AML)

Cancer of the blood and bone marrow affecting the myeloid cells

“Acute”due to rapid progression

Shortage of RBC when leukemia cells crowd around the blood making cells of the bone marrow

Symptoms Recurring infections, weight

loss, fatigue, fever, night sweats, and loss of appetite

Dx: based on lab measurements

+Tx. Plan – Preparative Regimen Cyclophosphamide

Days -6, day -5

Total body irradiation (TBI) Days -3, -2, -1

Primary goal: completely destroy any residual leukemia cells to make room for the new stem cells after transplant

Nutrition Related Side Effects: Mucositis, N/V, infections, suppressed immune system, dehydration

Monitor: weight, electrolyte levels, energy needs, increased nutrient needs NI-5.1

+Tx Plan - Bone Marrow Transplant Allogeneic Bone Marrow Transplant

Day 0 HLA-matched sibling bone marrow

graft versus tumor effect: stem cells develop into immune cells and identify the leukemia cells as invaders

Primary goal: replace destroyed bone marrow with healthy bone marrow stem cells Engraftment: the process of transplanted cells reproducing

new cells

Monitor: weight, electrolyte levels, energy needs

+Tx. Plan Intravenous cyclosporine

Instituted day-2 until day +180 Prophylaxis Graft versus host disease (GVHD)

Common side effect of BMT when transplanted immune cells attack the patients

body Side Effects: hyperkalemia, hyperlipidemia,

hypomagnesemia, hyperlipidemia Monitor: metabolic state, magnesium level- take regular

labs

Methotrexate Days +1, +3, +6,+11 Side Effects: mucositis, nitrogen catabolism, hypertension,

hyperglycemia, suppressed immune system Monitor: metabolic state glucose levels and weight-

increase energy needs

+Tx. Plan

Prophylactics for infection Fluconazole (Antifungal)

Day +1 Acyclovir (Antiviral) Day

+1

Antibiotics administered with onset of fever

IV morphine: pain management

Antiemetic Lorazepam Ondansteron

+Pt. Response to Tx.

Post BMT- Day 7 Severe mucositis- ice chips and

jell-o are intolerable diarrhea (650 cc/day), weight

dropped to 107lb Labs indicate malnutrition low

blood counts

Intervention place on TPN Increase energy and protein

Monitor Pt body weight and chemistry

and CBC labs to evaluate tolerance to TPN

+ Nutrition Therapy

Nutrients Mrs. Dean’s Needs

Protein 4% amino acid

Carbohydrate 16% dextroseFat 3% lipidFluids 1700 mLPotassium 50 mEqSodium 50 mEqCalcium 10 mEqPhosphorus 20 mmolAdult Multivitamin

10 mL/day

Adult Multimineral

1 mL/day

Parenteral Nutrition tube feeding is not

successful due to severity of N/V, mucositis, delayed gastric emptying, and diarrhea.

AML pt have low platelet count that increases risk of bleeding with enteral

PICC Two-in-one

Flexibility Precipitate

Needs Energy: 30-35 Kcal/kg Protein: 1.5 grams/kg

Branchamin

+Pt. Response to Tx.

 Day +16 Dx: stage I/II aGVHD

maculopapular rash on palms and trunk, bilirubin elevated (2.1mg/dL), stool output increased to 1200cc/24 hours

Intervention: Corticosteroid therapy Side Effects: anorexia, weight loss, elevated energy and protein

needs, hyperglycemia , nitrogen catabolism, hypertension, and sodium retention.

Day +20 blood glucose averaging 350 mg/dL

Onset of hyperglycemia due to use of corticosteroid therapy with treatment of I/II aGVHD

PN Intervention : start 1 unit insulin for every 10g dextrose Monitor: glucose levels, sodium, potassium, and fluids

Responded well to corticosteroid therapy  stool output decreased to less than 150 cc/dy Bilirubin stabilized and rash diminished

+Nutrition Therapy - TPN transition Clear liquid diet ( 3 days)

Total bowel rest Use of PN until diarrhea subsides

 GVHD diet Introducing lactose free, residue free, fiber free, and low fat

foods TPN weaned and discontinued by day +32

Intervention  Stage II GVHD diet

low lactose, low fiber until day +100

+Pt. Prognosis Recurrent Leukemia is main concern

Long term effects of AML treatment (CT, TBI, GVHD,BMT) Growth retardation, infertility, organ dysfunction, delayed

gastric emptying, catabolism, osteoporosis, growth suppression, poor wound healing, immunosuppression, infection

Monitor albumin levels

Take precautions to prevent infection

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Questions?

+What is the purpose of high dose chemotherapy and total body irradiation (TBI) treatment before bone marrow transplant (BMT) in patients with AML?

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What are the required protein needs for an individual receiving a BMT?

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References Mahan, L. K., Escott-Stump, S., & Raymond, J. (2012). Krause\'s food & the nutrition care process. (13 ed., Vol. 1). St. Louis: W B Saunders Co. Nelms, M., Sucher, K. P., Lacey, K., & Long Roth, S. (2011). Nutrition therapy & pathophysiology. (2nd ed. ed.). Belmont, CA: Wadsworth, Cengage Learning.

Leukemia--acute myeloid (myelogenous). (2012). Retrieved from http://www.cancer.org/cancer/leukemia-acutemyeloidaml/detailedguide/leukemia-acute-myeloid-myelogenous-diagnosed Acute myeloid leukemia treatment. . (Master's thesis, University of California )Retrieved from http://www.ucsfhealth.org/conditions/acute_myeloid_leukemia/treatment.html  Parrish, C. (2006, July). The hitchikers guide to parenteral nutrition management for adult patients. Retrieved from http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/MadsenArticle.pdf The leukemia/bone marrow transplant program of bc. (2011). Retrieved from http://www.leukemiabmtprogram.org Acute myelogenous leukemia. (n.d.). Retrieved from http://www.mayoclinic.com/health/acute-myelogenous-leukemia/DS00548  Engraftment. In The Free Dictionary. Farlex. Retrieved from http://medical-dictionary.thefreedictionary.com/engraftment